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EDI--successful and ahead of schedule.

More great strides have been made at the Division of Workers' Compensation and within the industry itself toward eliminating the filing of paper claim forms. The Electronic Data Interchange (EDI) rule, 69L-56, F.A.C., adopted Jan. 7, 2007, provided two separate implementation schedules for achieving complete electronic submission of the four highest-volume claim forms received by the division: DWC-1, First Report of Injury or Illness; DWC-4, Notice of Action/Change; DWC-12, Notice of Denial; and DWC-13, Claim Cost Report.

At the urging of the industry, the division allowed for gradual implementation of the required electronic submission of these documents and deferred inclusion of the DWC-4 electronic equivalent, which represented 40 percent of the above-referenced form volume, in a later phase of the Claims EDI mandate. The division expectation was that approximately 60 percent of the paper claims forms would be replaced by electronic transactions by the end of July 2009. However, a majority of the insurers, either filing directly or via third party administrators (commonly referred to as "trading partners") voluntarily elected to test and implement all of the required electronic form equivalents during the initial phase of the mandate, greatly accelerating the transition to electronic reporting.

By the end of March, 1,078 insurers (in active and runoff status), represented by 120 trading partners, had achieved full EDI implementation. Over 90 percent of the 22,269 First Reports of Injury or Illness forms and Claim Cost Reports submitted in February were submitted via EDI Release 3 (R3). For comparison purposes, the division received 33 percent via EDI for these same type claims forms and same time period a year ago. Once the remaining 23 trading partners still in transaction conclude their testing of the required electronic transactions, the division expects virtually 100 percent of the claims forms to be submitted via EDI, yielding a virtually paperless environment at the division for claims, medical, and proof of coverage filings by the end of July.

Better, Faster Data

In addition to receiving data in a more technologically efficient manner through EDI, the division is realizing a surge in data integrity and increased reliance in the accuracy of data collected in the new R3 electronic formats. The division has seen a decrease in filing and recording errors, and a resultant increase in the quality of the data submitted via the R3 national EDI standard. Enhanced program editing is allowing only those EDI filings that pass structural and business edits to be loaded to the division's claims database.

Although the division has experienced an increase in data quality since instituting the R1 program over 15 years ago, the current R3 program involves even more sophisticated editing of data by ensuring the receipt of required data in the proper sequence of events in the life of the claim, and blocking the receipt and collection of inaccurate data submitted out of order, resulting in more reliable data. Because notification regarding EDI filings that were not accepted (along with error message information that instructs proper correction and re-submission) are provided to the trading partner the following morning after transmission, corrected EDI filings are returned in a more timely fashion. This results in improved data accuracy and more timely availability of data to division associates when responding to requests for information and assistance. For example, during the last five years, a paper DWC-1 that once took division staff on average of 10 days to handle is now being processed the same day the electronic form equivalent is received. As a result, the division's Employee Assistance Office is able to offer its services to injured employees approximately ten days sooner.

Due to the division's aggressive strides in moving to an efficient technological approach for all business applications, a new verification process being conducted in concert with the federal Social Security Administrator is yielding information that allows the division to associate the correct Social Security Number (SSN) to its claims files and reconcile inaccurate information. As a result, duplicate claims are being eliminated from the division's database, and claim information for multiple accidents is being properly recorded under the same correct SSN. This enables the division to include all claim records under a particular SSN when claims records are requested.

Also, in an effort to identify data determined to be suspect in nature, as well as questionable filing patterns and practices not detectable by basic EDI program editing, the division will be generating in-house listings of claims that reflect questionable data or filing trends, and soliciting information from the trading partner to reconcile the data as necessary.

Warehousing Data

In an effort to make the division's data transparent and mutually beneficial for insurers, one unique feature in the division's EDI repertoire is the Claims EDI Data Warehouse, specifically designed with its trading partners in mind, and expected to be a model for other EDI states. This first-in-the-nation EDI data warehouse provides trading partners with a user-friendly view of all of its EDI filings and processing outcomes. It also includes courtesy listings that identify rejected filings not successfully resubmitted, accepted filings for which certain non-fatal errors generated by the division's program edits remain unreconciled, as well as claims where an exemption is on file with the division indicating that the injured employee may not actually be covered under the Florida workers' compensation act.

The data warehouse also enables a trading partner to generate its own "report card" for any given time period for either an individual claims office location or for all claims offices combined, to track performance. The report card reveals the five most serious errors causing rejection of the trading partner's EDI filings. Many trading partners are still experiencing errors as a result of the transition from paper to EDI, where discrepancies are identified between information previously reported (or not reported) compared to the current electronic filing, e.g., where one or more indemnity benefits, including salary in lieu of compensation, were reported on the paper DWC-1 but not included on the EDI transaction--a data element such as PI rating needed to validate payment of a particular type of benefit, is missing, and the like.

To better assist industry partners in monitoring their filing activity, the division has implemented several improvements to the data warehouse display and query functionality, some of which were suggested by the industry.

In an effort to maintain an up-to-date accounting of certain claim-related costs expended under the workers' compensation system, the division will be unveiling a new report this summer that will identify overdue bi-annual Electronic Claim Cost submissions. The division's own Bureau of Monitoring and Audit is also benefiting from the vast amount of information and history of electronic filings stored in the data warehouse when validating findings on a particular insurer's filing and payment practices when conducting audits and when responding to/reconciling disputes over late filing penalties.

Rule amendments to 69L-56, F.A.C., have been filed for adoption that will require changes in Proof of Coverage EDI transactions for Professional Employer Organizations (PEO), including the requirement to submit codes to identify a PEO and its clients. Further revisions to Rule 69L-56 are expected to be workshopped later this year or early 2010 that will clarify changes to the Claims EDI program edits, data element requirements, and filing expectations.

In summary, the EDI environment is providing the division the ability to take quicker action to address improper filing and payment practices and has the potential to leverage multiple data systems for cross-comparison and consolidation of claims information to the benefit of both carriers and injured workers.

Don Davis is chief of the Bureau of Data Quality and Collection at the Florida Division of Workers' Compensation.
EDI vs Paper

 Average Days
Calendar To Process
 Year DWC-1
RCVD Date Paper EDI

2004 9 0
2005 10 0
2006 12 0
2007 6 0
2008 15 0
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Author:Davis, Don
Publication:Florida Underwriter
Date:May 1, 2009
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